ESTATE RECOVERY NOTIFICATION OF DEATH
**To be used when the money is going to be sent to the Estate Recovery Program** Personal identifiable information will be used only in the administration of the Estate Recovery Program. Mail this completed form to the following address: Division of Health Care Access and Accountability Estate Recovery Program PO Box 309 Madison WI 53701-0309 Name -- Deceased Resident Social Security Number Date of Death

Total Amount of Funds at Nursing Home (Including Patient Account and Excess Patient Liability)

Dates Resident Resided in Nursing Home From To

Do not complete this form if a "yes" response is appropriate for any of the following questions. Does the deceased have a surviving spouse?

Yes Yes Yes

No No No

Unknown Unknown Unknown

Does the deceased have any surviving minor children under the age of 21? Does the deceased have any surviving disabled children? Name -- Nursing Home